A person diagnosed with liver failure now has a better chance of getting a transplant, thanks to the amended Human Organ Transplant Act and an SGH Liver Transplant Team that’s on standby round-the-clock.
2006, May 9, 9pm: A donor liver became available. The SGH liver transplant coordinator made an urgent call to a woman suffering from acute liver failure.
10pm: Patient arrived at SGH. Tests were carried out and confirmed she was fit to undergo liver transplant surgery. Surgeons made final preparations for the transplantation.
Midnight: Patient wheeled into operating theatre and anesthetised, with six surgeons in attendance.
Today, the patient 58-year old Ho May Mui has resumed her normal daily routine.(See other story) The administrative clerk was on the waiting list for a replacement liver for just four months. In the past, patients used to have to wait years for one to be available.
Changes to the Human Organ Transplant Act (HOTA) in 2004 made this possible. Previously, the law only allowed for the removal of a person’s kidneys if the individual died in an accident or was declared brain dead. The amended law now allows the removal of the liver, heart and cornea in the event of death from any cause for the purpose of transplantation. It is estimated that this would benefi t up to 80 transplant patients a year.
A liver transplant team is formed
Nine months after the revised HOTA came into effect, the Singapore General Hospital set up its Liver Transplant Programme. Dr Tan Chee Kiat, who is a senior consultant in the Department of Gastroenterology and Hepatology, heads the liver transplant team.
Since April 2005, the team has carried out seven liver transplants including on Madam Ho.
Dr Tan said, “We’ve done six dead donors and one live donor transplant. And we have started on our live donor programme because a live donor has an advantage. There is more control, in terms of timing. You can have a date of admission and preparation, whereas when we get a dead donor is totally unpredictable, and that’s why we need a 24/7 service. A liver transplant using an organ from a dead donor can occur any time and we cannot wait because the organ will deteriorate very quickly.”
The revised HOTA brought cheer to patients but for Dr Tan, more can be done.
“We anticipate that there will be more livers available because of this new bill. Now that we have the HOTA law, we can do more transplants because of suitability of organs. So one way to expand that is to have a living donor programme, which is a potential source of liver for our patients. We started this live donor programme last year and so, we ideally want to do one transplant a week or one a fortnight. That will really keep the wheels rolling, rather than roll and stop”.
There is growing demand to support Dr Tan’s aim of cutting down the waiting time for those whose livers have failed. After all, he works at the biggest liver department in Singapore where of the 40,000 annual outpatient attendances, half were of people suffering from liver conditions.
An individual needs a transplant when his liver fails as a result of liver disorder such as viral hepatitis, cirrhosis or liver damage from alcohol or drug abuse. A large portion of the liver must be damaged before liver failure occurs. Rapid damage over days or weeks is considered as acute renal failure while gradual deterioration over months or years is diagnosed as chronic liver failure.
To be placed on the liver transplant waiting list, the patient would usually have less than a 10 percent chance of surviving the following year.
Team-based approach
Soon after the revised HOTA was passed, SGH took the fi rst step of putting together its A-team of liver transplant personnel including surgeons, anaesthetists, hepatologists, intensivists, infectious disease physicians, radiologists, nurses etc. As transplant surgeries are complex, staff needed specifi c training in this fi eld. The search for talent was cast far and wide, even across the private sector.
It took the hospital about a year to form and build the capabilities of its existing Liver Transplant service team of about 60. This team is on standby round-the-clock. Comprising surgeons, anaesthetists, hepatologists, radiologists, nurses and intensive care specialists, some were deployed for training attachments in USA, Canada and the United Kingdom, three of the world’s most active countries in liver transplant surgeries.
The Liver Transplant service team’s surgical director Dr Prema Raj said, “We’ve drawn on the strengths of people from various places to work together to give to this service.”
The SGH visiting consultant took time off his private practice to join the Liver Transplant programme. He cherished the opportunity to better the lives of liver failure patients.
“I benefitted from a government award to study liver and pancreatic surgery and liver transplantation in Paris in the early 90s. Even though my bond ended 10 years ago, I felt that I owed it to the Ministry of Health and the public to help set up the liver transplant service in SGH. I have always had a passion for liver surgery and liver transplantation. So it was only natural for me to get involved even though it impacted on my private practice.”
Liver from the dead or living?
SGH’s liver transplant team is able to transplant livers from cadaveric which are removed from accidental death or brain-dead individuals and living donors.
So which of these is more effective? Both are equal, said Dr Prema Raj. For living donor transplants though, there are many factors to consider - - willing donors, suitability of blood type and body size, as well as the risks involved for the donor.
“With living donors, there is defi nitely always a potential risk. Unlike other transplants such as heart, kidney or cornea, liver transplants carry more risk. There are many intricate parts to join, including the vessels, veins, arteries and the bile ducts. If anything goes wrong at any point, it can spell disaster for the donor because without a functioning liver, the donor will die.”
But Dr Prema Raj pointed out the mortality rate of such surgeries was low. Since 2000, there were only about 19 deaths or just 0.1 percent of all liver transplantations performed around the world.
Saving lives first
The SGH team aims to perform about three living donor transplants per month. This will eventually be increased to one per week, including cadaveric transplants.
Dr Prema Raj said: “We’re looking at this transplant service as a service provided for the entire country, and not so much as to which institution provides it, because it makes no difference. Once a patient is placed before you, it doesn’t matter where you belong. The task at hand is to save that patient’s life, and everything else is secondary.”
All about Liver
Main functions
- Removes toxins from the blood
- Breaks down proteins, sugar and fats
- Stores nutrients absorbed from intestines
Causes of a damaged liver
- Excessive drinking and drug abuse – too much toxins in the liver causes inflammation
- Prolonged or severe infl ammation leads to cirrhosis, or scarring of liver
- Cirrhosis damages the liver’s regenerating function
Symptoms
- Abnormal blood test results
- Jaundice (yellowish eye whites or skin)
- Extreme tiredness
- Itchiness
- Weight loss
- Swollen legs & abdomen
- Nausea
Liver Care
- Hepatitis A & B vaccinations
- Limit alcohol intake to one glass per day
- Be aware of family’s medical history
- Eat and live healthily
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“Transplant saved me...”
SINCE the SGH Liver Transplant Team was set up in April 2005, seven patients have had liver transplants including Ho May Mui.
Five years ago, Madam Ho, 58, felt extremely lethargic and suffered from persistent itching. Luckily, she did not ignore what seemed like harmless symptoms. She consulted her family doctor and discovered that her liver was the problem.
“At first, my doctor could not say why I was itching so much. But on my third visit, he noticed that the whites of my eyes had turned yellow. He said it could be liver disease, and referred me to Singapore General Hospital immediately.”
The discolouration of Madam Ho’s eyeballs was an obvious and common tell tale sign of a damaged liver. Jaundice, which may also cause the skin to turn yellow, usually shows up at a later stage after non-specifi c symptoms of extreme tiredness and itchiness.
Within a month, Madam Ho was diagnosed with autoimmune cholangiopathy, an uncommon liver condition. This disease causes the body to attack and destroy its own liver bile ducts. The end result is liver failure.
In December 2005, despite medication to control her failing liver, the administrative clerk’s condition worsened. Madam Ho used ice packs to cope with the itching, and often took lunchtime naps in the offi ce because she was so exhausted. Her thighs and forearms were swollen, and her jaundice became worse. “My eyes were really yellow, and my skin turned from yellow to black,” she said.
Waiting list for transplant
Then, in January 2006, Madam Ho was told she might die without a new liver. “I felt weak, but apart from my itchiness and fatigue, I really didn’t think then that I was that sick.”
After some persuasion from her doctor and loved ones, Madam Ho put herself on the liver transplant waiting list. “To be honest, my hopes were not high about getting a new liver, because I knew getting an organ wasn’t easy. I’ve heard of patients waiting for 10 years just to get a kidney.”
Yes, some have lost their lives while waiting for a liver. A successful liver transplant depended on many factors. The most important factor is being able to fi nd a donor whose organ is a suitable match to the recipient’s blood type and size. Living donors or people who donate part of the livers to loved ones, face their own set of risks too.
Finally, on 9 May 2006 as Madam Ho was about to go to bed, she received unexpected news. She said, “At 9pm, I received a call from the hospital, saying there was a liver for me. I couldn’t believe it.”
The call was from the SGH liver transplant coordinator. A cadaveric liver was available for Madam Ho and the transplant team was ready to operate on her. Madam Ho recalled, “We reached SGH an hour later. After some tests, they said I was fit for surgery. At around midnight, they asked me to prepare to sleep”.
While she was under anaesthesia, six surgeons worked through the night to complete the life-saving transplant.
“When I regained consciousness, the first person I saw was my attending doctor, who told me the surgery went well. I didn’t feel exceptionally happy then probably because the truth had yet to sink in,” she recalled with a laugh.
A week later, Madam Ho finally had something to smile about. “My doctor told me, ‘Your children may seemed very calm in front of you, but behind your back, they were calling and asking us when you could have a liver transplant. They may not show it, but they’re very filial children.’ ”
Madam Ho now has resumed her normal routine and is thankful that she has been given a new lease of life. “Before my surgery, I was tired, sleepy and my complexion was very sallow. Now my skin looks better than it did a long time ago. And I’m really enjoying life with my granddaughter.”
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This article first appeared on Outram Now, May/Jun 2007.
Click here for the printed article:
Liver transplant-delivering new lease of life